A Picture is Worth More Than 1000 Words: How Advanced Imaging Is Improving Plastic Surgery and Aesthetic Medicine w/ Doug Canfield

Doreen Wu (00:00):
Welcome to another episode of Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Doreen Wu. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator, as well as our special guest, Doug Canfield, president of Canfield Scientific in Parsiphony, New Jersey. The title of today's episode is A Picture is Worth More Than a Thousand Words: How Advanced Imaging Is Improving Plastic Surgery and Aesthetic Medicine. We often start our episodes with a little history. So, Dr. Bass, what has the role of photography been in plastic surgery?

Dr. Lawrence Bass (00:40):
Photography is really central to documentation in plastic surgery, and it always has been. So this is very much like an orthopedic surgeon. The only way they can really map what they've accomplished is by using x-rays to see what happened to the bone before and after procedure, because what we do in plastic surgery is visible on the surface of the body. Photographic images of the patient before and after procedures is again central to that documentation. And it's so central that in fact, the first episode of this podcast discussed before and after images and photography standardization. That being said without that documentation, we really have trouble assessing results because we can't really remember what it looked like before. We think we remember, but we don't, our image of what we look like is probably fixed how we looked in our late twenties. And so we don't realize what that feature was like. And once you go and do a procedure, spend money go through recovery, then you start looking at everything very carefully and you start picking out features that were present before, but you didn't even realize were there. And so the only way to be real about what's happening is to have really good quality imaging before and after.

Doreen Wu (02:19):
Where has photography gone from there?

Dr. Lawrence Bass (02:22):
Well, you know, when I first started working in plastic surgery, which is round about 30 years ago, that was done with film. So we walked around with our camera bag and some rolls of film and everything was taken on film. Now, of course, photography is all digital, and that changed a lot of things. But images are digitally obtained and stored. They're presented on computer screens rather than printed out in paper photographs. And there's now three-dimensional photography and there's simulation of two-dimensional images and three-dimensional images. And so this is a lot like Photoshop except much more sophisticated and specifically designed and validated for medical use. And for that reason, we've brought Doug Canfield, who's the president of Canfield Scientific to speak with us today because Canfield Scientific is the leading company and really the pioneer in digital photography for plastic surgery. And now host of advanced solutions that we're going to discuss in a little more detail for the remainder of this episode.

Doreen Wu (03:50):
Going back to Dr. Bass's answer, we're gonna take these one at a time. So Doug, what are some of the advances in 2D photography?

Doug Canfield (03:58):
So, thanks, Doreen. You know, I think cameras digital cameras and lighting systems continue to improve, but the real advances have been in the software and those advances have allowed the clinical practices to take more standardized, higher quality before and after pictures, so that you really do have confidence in, in looking at your before and after photos and knowing that it's real change, true clinical change, and not some photographic artifact.

Doreen Wu (04:31):
And what about 3D photography? How is that different from 2D photography? What does it show that 2D photos cannot?

Doug Canfield (04:37):
Yeah, so stereo photogrammetry is actually a series of 2D views that are put together by an algorithm with lots of math and with these calibrated images to build a very accurate 3D model. And if you think about a 3D avatar of yourself that's very accurate, it allows for measurements to be made and allows for alignment between both pre-procedure and post-procedure to be matched. So you're really looking at the actual changes over time, and you can make area measurements and volumetric analysis. You can even do dynamic capture and look at things like skin stretch and skin elasticity. So lots of opportunity for making objective measurements in addition to the qualitative views that you get with 2D images.

Dr. Lawrence Bass (05:29):
You know, this has always been the challenge in aesthetic plastic surgery. A lot of what we look at is objective in terms of beauty and appearance, and the ability to create an objective measurement of change is really meaningful and really helpful.

Doreen Wu (05:48):
Exactly. And how has this changed the experience for the patients?

Doug Canfield (05:53):
So, you know, I think first for patients to be able to see their before and after pictures, it allows them to have confidence in the treatment or procedure that's been done. But you can also think about using that pre-treatment photograph as a communication tool. And instead of looking at before and after pictures of a different patient and a different outcome, you can personalize it and think of it as looking at your after before surgery. So this allows the clinician to work with the image and communicate with their patient what they believe is possible and appropriate for them. And this type of computer simulation, both with 2D and 3D, has really advanced in the recent years to be very realistic and appropriate for the types of procedures that are being done.

Doreen Wu (06:50):
Dr. Bass, what does all this mean for the plastic surgeon?

Dr. Lawrence Bass (06:53):
Well, it gives us an extremely powerful tool to show the patient clearly things we would have to explain in words or sometimes in diagrams. And this is critical both to precision diagnosis and also to treatment planning. We can show the findings and features that we're seeing on exam, and we always see some additional things in the images that we don't see when we look right at the patient in the exam room. We can simulate how the appearance would likely change with various interventions so the patient can gauge the importance to them and their individual aesthetic goals.

(07:40):
And that's an important thing because often a patient will explain what they want and they have one mental image in their mind, and I have a different mental image, and that's not going to work well at getting them the result they want. But if we're both looking at the same simulation and they say, "yeah, that's a good size for me with breast augmentation," or "that's the amount of reduction on the bump on my nose that I want or the amount of upturning of my nose that I want." I walk in the operating room with the exact same picture in my head as the patient has, we're more likely to get precisely to the result that the patient is hoping for than if I walk in with one mental image and they have something different. In addition to that, as Doug mentioned, we can show changes in before and after images with these advanced analysis tools that can show contour changes like volume loss after liposuction or breast reduction or volume medician like with a breast augmentation or when we do fat grafting or filler injections.

(08:57):
And these systems can map out exactly where and to what degree the surface contour has been changed, which is really, really elegant and really evocative for patients to understand what's going on. There are other tools that can look at skin smoothness or color evenness, things like that that can be analyzed as well. And a final thing for me is, and I thought it was interesting the way Doug described it, that a 3D image is really a series of 2D images that, that are being combined. But if I just have my six or eight standard 2D images that I take into the operating room, like in the old days when they were actually prints that's different. I can take the 3D image and rotate it on the video screen in the operating room, and see any aspect of the patient appearance that might come up during the course of the procedure. And that's far superior to what we got with just a few static images like in the old days.

Doreen Wu (10:09):
Are there any other ways advanced imaging is helping the plastic surgeon?

Dr. Lawrence Bass (10:14):
Well, you know, I love to do research, and photographic research tools help study, evaluate, and improve new treatments and procedures.

Doreen Wu (10:26):
Tell me, Doug, what role does Canfield Scientific play in performing research in plastic surgery, dermatology, anesthetic medicine?

Doug Canfield (10:34):
Thank you, Doreen. Canfield provides photographic documentation services to companies that are studying new products and devices for approval with the FDA. And in fact, I started the company offering standardized photographic documentation for facial imaging, and it was looking at topical retinoids for sun damage and think about products like retin-A today that were approved. They were approved partially based on high quality registered standardized before and after pictures. And today that's evolved. And in the aesthetic space, we not only work in skin rejuvenation and making claims there, but also injectables like toxins and fillers body contouring procedures and injectables for body contouring injectables for cellulite. All of these things can be documented in a very reliable, consistent way with 2D images. And some of them are really appropriate for 3D imaging as well. So we can look at durability of volume, let's say in a mid-face volume study. So we can know how long will that volume last in a phase. And by having a calibrated 3D image, we can actually see you know, the, the durability of the product. So it really gives us a much better understanding in reviewing some of the efficacy of these different products and treatments.

Dr. Lawrence Bass (12:10):
And I think this is critical, both for, of course, regulatory approval, which we need to have the product at all, but also for the clinicians to understand objectively in a quantitative data driven way, what nowadays we call evidence-based medicine what the performance of these different treatments and products are. And that helps us relate that same information to our patients. So Doug, we always like to talk about the future and what's coming. Of course none of us have a crystal ball and can guarantee, but someone at the cutting edge of this field like yourself probably has some notion of where things are really changing and where we're going to see exciting new developments. So what do you think the future of imaging is, let's say 10 years down the line?

Doug Canfield (13:12):
Already we're seeing, I think, evidence of how AI can help. So artificial intelligence is around us everywhere, and it's certainly around us with our digital images as well. So today we're introducing first impression software, which allows a patient or a surgeon to pick the trait that they want to most improve. And then using very large annotated data sets of different faces, being able to model that, how you can improve that first impression. So you want to look less tired that may show that you need to add a little filler in the Infraorbital Hollow below the eye or might skin resurfacing these little procedures that can add up. And it's a very powerful communication tool. So we're seeing AI in that space. We're seeing AI in the diagnostic support space coming through. So we're actually going to see clear devices that are used by clinicians to make early diagnosis of things like skin cancer. And that's all in the frontier and happening today. And I'm pretty sure in 10 years time we're gonna see a lot of different methods approved methods by the FDA of using imaging as a class two and maybe even a class three medical device

Dr. Lawrence Bass (14:41):
That's really interesting. And I think just so our listeners can understand, when you say a large annotated database, how many entries are you talking about? Just to give people a sense.

Doug Canfield (14:53):
Usually data scientists talk in terms of tens of thousands. For many of our skin cancer modeling databases we have over a hundred thousand annotated images. Some have millions. And of course the quality of the data sets are really important. And they are annotated. So somebody a human is actually deciding what is in these images and teaching the computer then how to interpret this data, and that's the part that just keeps getting better and better.

Dr. Lawrence Bass (15:27):
So this sounds like a tremendous amount of hard work and a lot of lead time to get these things to a usable state with a lot of very smart people working on it.

Doug Canfield (15:41):
Absolutely. These aren't easy things, but I think they're going to be important for the future of imaging and how it can bring value to both patients and to surgeons and and practitioners.

Doreen Wu (15:54):
That is truly fascinating. And lastly, before we wrap up the episode, Dr. Bass, do you have any takeaways for our listeners?

Dr. Lawrence Bass (16:02):
As we said at the beginning, photography has always been central to assessing our results in plastic surgery. And these advanced imaging technologies have just taken that to a whole other level and made the utilization of images, and after all this is plastic surgery, how things look is what it's all about, so it's made it even more central to the consultation, to the treatment planning, to the execution of the treatment and the assessment of the results. So with that, I'll thank Doug for joining us from Canfield Scientific and sharing his expertise on what's happening in this field of advanced imaging in plastic surgery, dermatology, and aesthetic medicine. It's really been a pleasure and I echo Doreen's comment that this area is truly fascinating and exciting and we're looking forward to all the new tools that your company is going to put into our hands.

Doug Canfield (17:11):
Thank you Dr. Bass. And thank you Doreen. This podcast has been a lot of fun and it's been fun to reminisce about 35 millimeter film and what we're doing today with AI. And I do believe in the future we will be able to use these trained data sets to be useful, clinically useful for both the patient and the clinician to be able to provide and learn what is possible with patient procedures.

Doreen Wu (17:38):
Thank you Doug, again, for taking the time to share your insight and expertise with us and illuminating us with what's to come. And thank you to our listeners for joining us today to hear about the important role photography and advanced imaging in aesthetic medicine. I hope you found this episode as fascinating and informative as I did. If you think of other exciting developments or trends in plastic surgery that you would like us to discuss in upcoming episodes, please reach out by email or Instagram. We'll see you next time. This is Doreen Wu thanking you for joining Dr. Bass, Mr. Doug Canfield of Canfield Scientific, and me for this riveting discussion of photography, advanced imaging and plastic surgery. Be sure to tune in next time and don't forget to subscribe to our podcast to stay up to date with all of the exciting content that is coming your way.

Speaker 4 (18:24):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class podcast with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor patient relationship is established by listening to or participating in this podcast. Consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.